Client Intake Form

Name *

First

Last

Date *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number *

Email *

In Case of Emergency

Who may we thank for your referral?

What is your main skin concern for your visit?

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Your Physical Health

Have you been under the care of a physician for any reason in the past year? *

Please Explain

Have you had any recent surgeries including piastre surgery in the past year?

Please Explain

Please check any of the following conditions you have or may have had in the past;

Cancer
High Blood Pressure
Epilepsy
Immune Disorders
Sinus infection
Hormone Imbalance
Thyroid Condition
Seizure Disorder
Blood Clots
Claustrophobia
Hepatitis
Heart Condition
HIV/AIDS
Skin Disease
Insomnia
Herpes Simplex
Varicose Veins
Lupus
Keloid Scarring
Allergies
Cold Sores/ Canker Sores
Eczema
Pacemaker
Acne
Autoimmune Disease/Disorder

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Identify your stress level

Low
Medium
High

List all medications, herbs or vitamins you take on a daily basis;

In the past three months have you used any of the following; Accutane, Retin-A, Renova, Glycolic Acid, Salicylic Acid, AHA or Retinol/ Vitamin A derived products?

Have you used any type of medication for acne conditions?

Are you pregnant or trying to get pregnant or breast feeding?

Are you taking Oral Contraceptives?

Are you pre menopausal, in menopause or post menopausal?

Do you smoke?

How many per day?

Are you currently dieting or on an exercise program?

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How much do you consume in a day?

Water

Alcohol

Caffine

Soda

Have you been exposed to the sun or used a tanning bed in the past 24 -48 hours?

Do you wear contact lenses or glasses?

Have you ever had an adverse reaction after using any skin care product?

Have you ever had an allergic reaction to any of the following: Check all that apply.

Cosmetics
Pollen
Fragrance
Food
Shellfish/Seafood
Animals
Latex
Sunscreens
Drugs
Iodine
AHA
Other

Please Explain

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Have you had skin care treatments in the past?

Do you usually breakout after skin care treatments?

Have you ever experienced unexplained itching, swelling, flaking or redness after a facial?

Do you use a sun block daily?

Is there anything that we should know that was not previously mentioned so that we may better service you?

What is your current home care regimen?

Cleanser
Toner
Day Moisturizer
Night Moisturizer
Serum/Concentrate
Scrub
Mask
Sun Block
Other

Please Explain

Your visit to our skin care clinic is the beginning of a positive relationship between you and our aesthetician. Effective skincare and a professional skin care regimen is important in maintaining healthy skin.

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